| NPI | 1467894915 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: AZ D9977) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 62489) |
| Enumeration Date | 2013-07-25 |
| Last Update Date | 2021-06-01 |